Strategies for Diagnosing & Treating Peyronie’s Disease

Dr. Doghramji:
Did you know that, according to the Urology Care Foundation, 1–23% of men between the ages of 40 and 70 may be affected by penile curvature, or Peyronie’s disease? And while the exact cause is still unknown, the important thing to remember is that there are diagnostic tools and treatment options available to us to help those living with this under-recognized condition.

Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Paul Doghramji, and joining me today is Dr. Alexander Pastuszak, a urologist who specializes in the treatment of male infertility and sexual dysfunction.

So, Dr. Pastuszak—Alex, thanks for joining us today.

Dr. Pastuszak:
Yeah, thanks so much, Paul. It’s really good to be here. I’m so happy to be talking to you guys about Peyronie’s disease today.

Dr. Doghramji:
To start with, Alex, what’s Peyronie’s disease, and why does it occur to begin with?

Dr. Pastuszak:
Excellent question. So, Peyronie’s disease sort of by definition is an abnormal curvature of the penis—at least that’s how most men see it—and it can be a curvature, it can be a deformity of any sort, so a twist in the penis, a dent in the penis, an erection that changes from the beginning, the bottom of the penis going out to the tip of the penis at a certain inflection point. And what typically causes Peyronie’s disease is a formation of scar tissue in the penile corpora cavernosa. The corpora cavernosa are surround by a fibroelastic sheath called the tunica albuginea, and scar tissue can form in that, and when scar tissue forms, it contracts, and that contraction is what causes the penile deformity, whether it’s a curvature, an indentation, or what have you. So, it’s really this abnormal scar tissue forming in the tunica albuginea of the corpora cavernosa that causes the defect and the symptoms associated with the condition.

Dr. Doghramji:
And this just happens or is seen, rather, with an erection. You can’t really see it when it’s in the flaccid state; is that correct?

Dr. Pastuszak:
That’s right, but a lot of men, when they feel their penis, can sometimes feel a lump or a bump, and that can be very disconcerting to them, and they will come in with either an abnormal curvature as they see it on erection or even come in saying, “Hey, doc, you know, I felt this lump in my penis. Do I have cancer? What’s going on?” And then you get down into the discussion.

Dr. Doghramji:
And you also said that there can be pain. Is it common for pain to occur with Peyronie’s disease, or is it more often just a deformity without pain?

Dr. Pastuszak:
That’s a great question. The majority of men do not present with pain, although a fair number do, and the majority of men also don’t present with knowing that they have had had an injury to the penis, because there has to be something that triggers the formation of the scar tissue. So, by and large men don’t always present with pain, but those that do let you know right away that they have pain either with an erection or even with a flaccid penis.

Dr. Doghramji:
Absolutely. So, Alex, I’m sure it’s not the most comfortable topic for a male patient to bring it up, so how do you open the conversation with a patient who has this and put him at ease?

Dr. Pastuszak:
So, by the time they’re in your office, they’re ready to talk to you about it, but I think stepping outside of the office, our listeners should know that there are a lot of men who have Peyronie’s disease. Thirteen percent of the general population is the current estimate. It may actually be higher, so these guys are not alone. It’s normal for these guys to feel anxious or depressed about it. As a matter of fact, some of the evidence in the literature says that up to 50% of men with Peyronie’s have signs of clinical depression. And ultimately, for the guy coming into your office and talking to you about this, Peyronie’s is extremely highly treatable. Almost everybody can be treated.

Dr. Doghramji:
So, what are some of the more common genetic traits or predisposing factors that may determine if a male patient is suffering from Peyronie’s disease? Is there a certain demographic that’s most effective?

Dr. Pastuszak:
So, Paul, I’m going to take that question in a couple of different parts. So, in terms of a certain demographic, so there have been hot spots in white males, particularly those of Celtic descent. Some of this is still being kind of determined, but we do know that Peyronie’s can be genetically inherited. As a matter of fact, some of my research really focuses on determining the familiality of this condition itself, and that’s some exciting work we’re doing here up at the University of Utah. We don’t know exactly the genes that cause it to be passed on. We’re working on figuring that out.

But there are a number of conditions that are associated with Peyronie’s disease, but whether they are actually causally related is unclear. But just to kind of highlight those for our listeners, men with Peyronie’s disease also, a large percentage of the time, present with erectile dysfunction, and whether those are related is not clear. Men with Peyronie’s also tend to have diabetes, and it’s not clear whether it’s the diabetes that drives the Peyronie’s or potentially vice versa, if this is actually a systemic condition. Men with Peyronie’s also often come in with low testosterone. And as I mentioned, about 50% of men with Peyronie’s, or up to 50%, can have signs of clinical depression. There are also a number of conditions that we’ve identified through our clinical research over the past couple years that are just coming out in the literature that are associated with Peyronie’s, and these include prostatitis, BPH—or benign prostatic hyperplasia, or prostate enlargement—as well as keloid scars and a number of cancers. So, again, the causality here is not clear. These are largely statistical associations but I think important for people to know about.

Dr. Doghramji:
Such novel information, thank you, Alex. Let’s talk next about the signs and symptoms that a patient may experience with penile curvature, Peyronie’s disease. Can you go into that, please?

Dr. Pastuszak:
Yeah. Usually, guys come in with pain in the penis, a lump, or probably the most obvious is curve, right? when you’re actually having the curvature that comes with Peyronie’s that actually is the definitional aspect of it, so it kind of is across the spectrum what guys come in with. Probably, most commonly they are going to come in with a curve, and most commonly that curve is going to be upwards, but they come in all shapes and sizes. And bottom line for any patient, if you have any discomfort in your penis, if you have any type of deformity or change in the way your penis looks that it didn’t look like a few weeks back or a couple of months back and you’re concerned about it, that’s a reason to go get checked out; or if your partner is complaining that something isn’t quite right, that’s a reason to go get checked out.

Dr. Doghramji:
Wow, interesting. So, Alex, how long does the usual man wait until he goes and gets checked out, out of curiosity?

Dr. Pastuszak:
That’s a great question, so anywhere from 2 years to 4½ years—

Dr. Doghramji:
Oh my gosh.

Dr. Pastuszak:
—on average.

Dr. Doghramji:
Wow.

Dr. Pastuszak:
Yeah, men do not like going to the doctor, unlike their female counterparts. They do not like seeing us.

Dr. Doghramji:
Very interesting. For those tuning in, this is Clinician’s Roundtable on ReachMD, and I’m Dr. Paul Doghramji, and today I’m speaking with Dr. Alex Pastuszak about diagnosing and treating penile curvature, which is also known as Peyronie’s disease.

So, Alex, let’s go on. Now that we’ve covered some of the signs and symptoms we should be on the lookout for, what diagnostic tools are there? What tests are there that are available to examine and pinpoint plaque building inside the penis?

Dr. Pastuszak:
So, starting very simply, you’ve got your eyes and your hands as both the patient and the doctor. You can feel potential lumps and bumps on the penis. And again, that’s a reason that patients come in. And, obviously, you can see a change in the appearance of the penis. But then, as clinicians, there are other things that we should at least consider doing if not certainly do in centers of excellence that include checking hormone levels. So, I mentioned that a large number of men with Peyronie’s come in with low testosterone. Knowing that isn’t necessarily going to change the course of the Peyronie’s but can change that man’s life in terms of how he feels. Other things for diagnosis include specialized ultrasonography, like what’s called a penile duplex ultrasound where we evaluate the penis and the structures of the penis, meaning the corpora, which are the bodies that actually develop the scar tissue that results in curvature, the blood flow into the penis and the actual curvature very objectively, and we can see where plaques are, and what that really does for us as clinicians is it helps us plan treatment. And we’re probably going to talk about that at some point, but there are a number of therapies, and which one is best for the patient in part depends on what the signs, symptoms and findings are on evaluation.

Dr. Doghramji:
Well, Alex, let’s get right to that. So, once a patient has been diagnosed with Peyronie’s disease, are there surgical and nonsurgical treatments, and what’s the right thing for these patients?

Dr. Pastuszak:
Yes, so let’s have some straight talk and hard facts on Peyronie’s disease, right? There are indeed a number of nonsurgical and surgical treatments, and I like to describe these in 4 categories. So the first category is penile traction therapy, and this is really outside the realm of the physician in the sense that you don’t need a prescription to get a device that can “do penile traction” for you, and you don’t need a physician to monitor this treatment, but what you can do is essentially go on the web, go to a medical specialty store potentially and buy a device. It kind of looks a little like a scalpel that you can put on your penis, and what it does is it stretches the penis. And the advantage to stretching is that—there are some early data that show that stretching consistently for several hours a day over the course of weeks to months can help straighten the penis, so that’s sort of the do-it-yourself or DIY approach to Peyronie’s disease. It will cost you a few hundred bucks, but it can certainly be effective.

Category 2, 3 and 4 really are the domain of the physician-patient relationship. The second category, which I have to include, but we really don’t use in our practice here, are oral therapies, and these can range from stuff like supplements and antioxidants like vitamin E, to amino acids like L-Arginine, to drugs like pentoxifylline. There is a lot of sort of potential for these, but no clinical studies have to date shown that there’s really any efficacy. As a matter of fact, the American Urological Association, which is the sort of largest professional society in urology, released a guideline in 2015 that advocated essentially against the use of any oral therapies, so we don’t use them in our practice, but patients and clinicians should know about them because they are out there.

And then the third category are really what we call intralesional injections, and these are injections of drug into the plaque itself. And there are a number of these which have proven efficacy, , when injected into the plaque itself, can help dissolve that plaque or prevent more plaque formation and was shown in clinical trials that they can help straighten the penis. Upside is that you’re just getting a needle in the penis. I know that guys don’t like to hear that, but ultimately, when they go through it, it’s not all that bad. It’s just a little prick, as we like to say. The downside is that you usually need to make a commitment, so these are several months of therapy typically in cycles.

And then finally we get to surgical therapy, and there are a lot of really excellent surgical therapies out there, three or four. I don’t want to spend a ton of time on those, but the bottom line is that these can be 90–100% effective depending on which one you choose. Selection of these absolutely needs to be shared decision-making between patient and the physician, but they can work really well, really quickly, and the patients do really well.

Dr. Doghramji:
A lot of treatment options for patients then. So, before we wrap up, I’d like to open the floor to you, Alex. Is there anything we haven’t covered that maybe you’d like to share to our listeners about Peyronie’s disease?

Dr. Pastuszak:
I think 2 points: Number 1, just speaking directly to the listeners, whether they are patients or physicians, this is an underdiagnosed and underserved condition. There is a fair bit of expertise about how to treat it. You just need to find the right people, and they are all over the United States and the world. There’s not a million of them, but any major city will have an expert with experience in treating Peyronie’s disease, and if you don’t know them, you can always ask a friend or even me. And then speaking to the patients, this is not something that you should be embarrassed about. We would rather, and I think you would rather, have the opportunity to have a fulfilling sex life and relationship, and we can help you with that. There are a lot of ways that we can get you straight.

Dr. Doghramji:
Excellent information. So, Alex, I’d like to thank you for shedding light on this largely overlooked topic and for helping our audience understand the causes and treatments for male infertility, and specifically Peyronie’s disease. It was a great pleasure having you on the program today.

Dr. Pastuszak:
Well, thank you so much, Paul. I really appreciate the invite and the opportunity to talk to you.

Dr. Doghramji:
And I am Dr. Paul Doghramji, and you’ve been listening to Clinician’s Roundtable on ReachMD. To access this episode and others in the series, visit ReachMD.com/clinicians-roundtable where you can Be Part of the Knowledge.